W ORKING S ESSION : C REATING AN HCV C URE C ASCADE Danica Kuncio, - PowerPoint PPT Presentation

W ORKING S ESSION : C REATING AN HCV C URE C ASCADE Danica Kuncio, MPH Viral Hepatitis Program Manager Philadelphia Department of Public Health NASTAD National Hepatitis Technical Assistance Meeting Washington, DC November 29th, 2017

S ESSION O UTLIN E Session Outline 1. Philadelphia’s Cascades Overview 2. Table Discussions 3. Report Out to the Group 4. Open discussion

HCV Care Continuum Linked to HCV RNA HCV Ab Treated Cured Untested confirmed specialist care screened PHILADELPHIA’S CASCADE

M ETHODS 1. HCV Ab - Positive Estimate: Adjusted for likelihood of being tested in the study period 2. Screened: Unknown 3. HCV Ab positive: Surveillance Data 4. HCV RNA tested: Unknown 5. HCV RNA - positive: surveillance data 6. In Care: • ≥ 2 HCV RNA tests reported ≥ 6 months apart • ≥ 1 HCV test ordered by a Hepatologist , GI, or ID specialist 7. Treated: Investigation findings à projected for population 8. Cure/SVR: Unknown

R ESULTS 50000 30000 25000 20000 Number of individuals 47% 15000 10000 22% 5000 6% 3% 0 HCV infected HCV Ab HCV RNA HCV in HCV antiviral (estimate) medical care treatment Proportion of HCV - infected individuals reaching successive stages HCV - positive individuals are being lost at all stages of the HCV testing, referral to care, and treatment cascade

O RIGINAL P HILADELPHIA HCV C ONTINUUM OF C ARE , 2010 – 2013 60,000 16,000 100% 14,000 15% Treatment Initiation 50,000 A mong Confirmed+ Cases 12,000 40,000 Number of Cases 10,000 30,000 8,000 47% 6,000 20,000 4,000 10,000 13% 2,000 7% 55% 27% 13,596 6,383 1,745 956 47,525 28,990 0 0 AB+ Received Confirmatory In HCV care HCV Total HCV Ab+ Ab Tests RNA+ Treatment* Estimate Expected Estimate

30000 25000 ? 20000 15000 10000 5000 0 HCV infected HCV Ab HCV RNA HCV in medical HCV antiviral (estimate) care treatment USING THE CASCADE TO INFORM ACTIVITIES AND UNDERSTAND HCV IN PHILLY

L INKAGE I NITIATIVES • Education of Patients – Created Philly - specific Educational materials to distribute to new cases – Phillyhepatitis.org provides resources for education and linkage – Provide materials to community partners • Perinatal HCV Program ⁻ Importance of mom & infant being in care for HCV • Work with Philadelphia’s syringe exchange program (Prevention Point) ⁻ Investigators draw blood from any HCV Ab - positive clients ⁻ Screen for RNA and ⁻ RNA - positive clients are linked to care by case workers

T REATMENT U PDATE A MONG I NVESTIGATED C ASES • Follow - up with previously investigated cases – Have you been treated since we last spoke? – Experiencing barriers to treatment? – Clarify misinformation about treatment restrictions – Provide linkage resources Important to remember our data is not static à reevaluation is necessary

U PDATED : P HILADELPHIA HCV C ONTINUUM OF C ARE , 2010 – 2013 60,000 16,000 100% 14,000 50,000 31% Treatment Initiation A mong Confirmed+ Cases 12,000 40,000 Number of Cases 10,000 30,000 54% 8,000 20,000 6,000 36% 10,000 4,000 1 7 % 66% 47,525 28,990 2,000 47% 0 Total HCV Ab+ Ab Tests 13,596 7,344 4,852 2,273 Estimate Expected 0 Estimate AB+ Received Confirmatory In HCV care HCV RNA+ Treatment*

O RIGINAL AND U PDATED HCV C ONTINUUM OF C ARE , 2010 – 2013 16,000 14,000 Cohort 1 (Original) Number of Cases Cohort 1 (Updated) 12,000 15%* Increase 10,000 178%* 8,000 Increase 6,000 4,000 138%* Increase 2,000 0 AB+ Received Confirmatory RNA+ In HCV care HCV Treatment* * p - value < 0.05

HCV Care Continuum Linked to HCV RNA HCV Ab Treated Cured Untested confirmed specialist care screened OTHER USES

A CUTE HCV O UTCOMES , 2012 - 2016 • Any new potential acute case is investigated - and receives outreach if not LTFU • Measure the success of the intervention 160 100% 140 Outreach (N=142) 120 86% 100 No Outreach 67% (N=147) 80 80% 60 33% 40 20% 14% 11% 20 2% 0 N=289 Total Cleared Chronic Specialist Treated

HIV - HCV C OINFECTED & HCV M ONOINFECTED • In City of Philadelphia 3,086 (16%) PLWH are co - infected with HCV • Matched HCV and HIV surveillance datasets 100% 100 82% 80 70% Percentage % 67% 56% 56% 60 37% 40 28% 15% 20 0 HCV Ab - Confirmatory Confirmatory In HCV care Resolved Positive RNA Received RNA Positive Infection HCV Monoinfection HIV/HCV Coinfection

T HANK Y OU ! Acknowledgements Contact Kendra Viner Danica Kuncio Dana Higgins Danica.kuncio@phila.gov Caroline Johnson Alexandra Shirreffs AIDS Activities Coordinating Office Phillyhepatitis.org https://hip.phila.gov/DiseaseControlGuidance/DiseasesConditions/HepatitisC

EXTRA SLIDES

SCALE DOWN THE CASCADE • Use whatever data you have to assess particular steps in the cascade ( ie . the drop off from Ab - only to Ab+RNA ) – Everyone can create a local estimate! • Assess cascade at sentinel sites • Assess cascade for special populations - Youth - Baby Boomers - Homeless - Incarcerated Individuals - IDU - Other?

BARRIERS 1. Manpower 2. Legal: – Access to Behavioral Health/Other data sources held up by law 3. Data silos: – Access held up by red tape 4. Data Content: – No race/ethnicity information from our reported labs 5. Cost – Even if you don’t use surveillance data, how can you pay for any time spent to build and change cascade? – Linkage to care, testing all require $$

WHY CREATING A LOCAL CASCADE IS WORTH THE EFFORT • Localities often more likely to get identified data • Easier to identify groups at increased risk of falling out of the cascade • Reasons for falling out may be region specific ( eg . In Philadelphia, MATs are unable to perform RNA testing) - Policy change may need to be state/city level • The National picture may not be representative of the local experience – Can use data to inform National efforts with local data • Any information is helpful information!!

USE ALL ACCESSIBLE DATA • Vital stats – birth records and death c ertificates • Negative Testing • MCO Claims • Behavioral Health • Medical Examiner • Pharmacy • Other Payers • EMR • Inpatient/Outpatient PHC4 data • Other Health Department data (STD, HIV, etc.) • Cancer registry data

METHODS 1. Estimate HCV seroprevelance for Philly – Age, gender, and race/ethnicity specific NHANES rates à 2012 US census estimates (adjusted for deaths, births, etc ) – Refined using high - risk institutionalized group estimates excluded from NHANES (homeless, incarcerated) Viner et al. The Continuum of Hepatitis C Testing and Care. Hepatology 2015 Mar;61(3):783 - 9. * Chak et al. Hepatitis C virus infection in USA: an estimate of true prevalence. Liver Int 2011;31:1090 - 1101

P HILADELPHIA HCV C ONTINUUM OF C ARE , C OHORT 2 (2014 – 2016) 60,000 14,000 100% 28% Treatment Initiation 12,000 50,000 A mong Confirmed+ Cases 10,000 40,000 Number of Cases 8,000 30,000 46% 6,000 20,000 4,000 20% 10,000 13% 2,000 43% 65% 54,131 21,743 11,525 5,301 2,272 1,469 0 0 AB+ Received Confirmatory In HCV care HCV Total HCV Ab+ Ab Tests RNA+ Treatment* Estimate* Expected Estimate

P HILADELPHIA HCV C ONTINUUM OF C ARE , C OHORT 1 & C OHORT 2 100% 100% Cohort 1 (2010 - 2013) Cohort 2 (2014 - 2016) 80% 60% 47% 46 % 40% 20 %* 20% 13% 13 %* 7% 0% AB+ Received Confirmatory RNA+ In HCV Care HCV Treatment* * p - value < 0.05